HIV/ HEP C 2013Dr Mike Silverman MD, FRCP, FACP

Positive Care Clinic, Whitby

PROGNOSIS

• 30 MSM year old infected today can expect same lifespan as HIV negative IFF no additional risk factors

• Previous data regarding survival- loss of 5 years (older drugs not as effective and more side effects)

• Smoking- loss of 12 years of life also lower quality of years you have- [more likely to suffer many complications](heart attack, stroke, cancers, emphysema, leg loss, kidney failure etc…)

• Champix/ nicotine patches+gum/ wellbutrin

• IDU- overdose, infectious complications (more common especially early on Rx and makes it hard to remember to take meds)

• So good news- HIV can be controlled- but we need to take care of addictions

Tanser F, et al. CROI 2012. Abstract 136LB.

ART Coverage (% of All HIV+ Pts on ART)

*Adjusted for age, sex, community-level HIV prevalence, urban vs rural locale, marital status, > 1 partner in last 12 mos, and household wealth index.

0

1.00

Adj

ust

ed H

R f

or

HIV

Acq

uisi

tion*

0.20

0.40

0.60

0.80

> 4030-40< 10

1.20

10-20 20-30

P = .59

P = .002

P < .001 P = .016

LOWER RISK OF HIV ACQUISITION WITH BROADER ART COVERAGE IN RURAL S.

AFRICA• Hlabisa, South Africa: rural community with 24% adult HIV prevalence

• 20,000 pts started on ART since 2004

• 1413 seroconversions observed; HIV incidence estimated according to time-adjusted ART coverage in local community

TRANSMISSION

• O52- implications

• Legal regarding disclosure- if use condom not required (easier for relationship than disclosing later…if relationship is goal)

• Pregnancy without IVF? Using PreP?- still need to work with MD, but doable!

• PreP- 60% protective using oral tenofovir- great deal of variability based on whether PreP actually taken

WHEN TO START ON RX?

• CD4<500- Why?

• Higher risk of heart disease, kidney disease, liver disease if not on Rx (chronic inflammation)

• Drugs are now so much safer and easier to take, even though risk of AIDS illnesses (pneumonia and other infections, cancers) doesn’t start rising until CD4 lower, accelerated aging occurs if not on treatment from inflammation so start earlier

• What if CD4>500?

• If any heart or kidney or liver disease, (including Hep B or C) or in discordant relationship- should be on Rx

• Should everyone be on Rx?- debated- studies to clarify this are ongoing

HOW ABOUT NON-PROGRESSORS?

• Very rare (~0.7% of Europeans, 0.3% of African descent)

• Some very lucky –undetectable viral load even though never on Rx (elite controllers)

• VERY rare, much more common, “slow progressors”

• More likely to be a slow progressor if treated when acutely infected

• Not commonly recognized (flu like illness+/- rash, or more commonly no symptoms at all)

• Attempt to recognize early

• Even Elite non-progressors likely should be treated in some cases to prevent premature aging

PEOPLE STARTING ART AT HIGHER CD4+ CELL COUNTS OVERALL, BUT DISPARITIES REMAIN

• In San Francisco study, overall trends of starting ART at higher CD4+ counts, but pts initiating ART at CD4+ counts > 350 cells/mm3 significantly more likely to be white, older, MSM, nonpoor, and diagnosed by private provider[2]

1. Mugglin C, et al. CROI 2012. Abstract 100. 2. Truong HH, et al. CROI 2012. Abstract 139.

307246

225

262252

150 286

118

89145-176

137 140234

CD4+ cell count at start of ART (cells/mm3), 2009[1]

Low incomeMiddle incomeHigh income

200

185

STILL HAVING A PROBLEM THAT HIV IS DIAGNOSED LATE ESPECIALLY IN SMALLER

COMMUNITIES IN CANADA• More advanced disease

• Harder to get viral load down

• Often present with serious and sometimes life threatening problems

LOTS OF NEW MEDS

• Now 3 Single tablet formulations to choose from and all covered-ODB

• Atripla- Tenofovir+FTC+Efavirenz

• Complera- Tenofovir+FTC+ Rilpivirine

• Stribild- Tenofovir+FTC+cobicistat+elvitagrivir

• Issues- Food, antacids, drug interactions, blood monitoring, timing of treatment

• Vs nightmares, anxiety, high cholesterol

• New one –Abacavir/3TC/dolutegravir on the way

OLDER CHOICES (MULTIPLE TABLETS) STILL VERY GOOD

• Raltegravir (Isentress) - twice daily but very durable response and almost no side effects

• Ritonavir (norvir) boosted- atazanavir (Reyataz)/darunavir (prezista)- once daily

• ritonavir/lopinavir (kaletra)- twice daily so less often used

• Nevirapine (now once daily), Intelence (2tabs once daily)

• Kivexa- now can predict allergy with genetic testing- concerns about heart disease seem to be waning

• Maraviroc- good drug- twice daily- not easy to get coverage

• AZT- rarely used except in pregnancy, and newborns

• Old drugs (ddI, d4T etc..) replaced by much better options

• No longer lipodystrophy, atrophy

LOTS OF CHOICES

• No one right answer

• Need to discuss side effects and lifestyle with doctor to see what works best for you

DRUG HOLLIDAYS

• Like any vacation these can be very “expensive”

• Irreversible drug resistance can occur- if restart meds may not work and all meds in same family also will not work

• When our medications were toxic these had some rationale

• We now know much more likely to die or have serious complications such as heart attack, stroke, kidney or liver problem if use a drug holliday

WHAT ABOUT SHORT HOLIDAYS- IE MISSING OCCASSIONALY?

• Missing >10% of pills dramatically increases risk of irreversible drug resistance

• Safest approach is keep a routine so never miss

• Keep extra tablets with you in case sleep over somewhere

• Take at same time so becomes a habit

• If uncertain about ? Side effect- contact clinic as can switch to something new. MUCH safer than stopping for a bit then starting something else

• Note: if holidays occur- and then resistance- usually can’t use one tablet, once daily regimens anymore

HIV VACCINE

• Some promising developments but none ready for prime time yet

• If already positive -Need to keep undetectable viral load so that may be able to be on vaccine when available then “stop meds”

• New drugs to “get rid of viral reservoir” in development- work better the longer you have been undetectable

WHAT IF I CAN’T GET TO UNDETECTABLE?

• Make sure not forgetting more than you think?

• Recheck all medications? Drug interactions- smoking cigarettes/marijuana?

• Check blood levels- sometimes if very large person or fast metabolism need a larger dose

• Sometimes 3 drugs are not enough and need a fourth

• (now that much less toxic this isn’t so bad)

CURE?

• Berlin patient- now 2 Americans – bone marrow transplant

• 30% 1 year death rate so only done if another reason- leukemia/lymphoma

• Worked even in non-CCR5 negative bone marrow donor

• Recent Baby- very early treatment x 18 months then stopped

OVERLAPPING HCV & HIV EPIDEMICS

40 million170 million

10 million

HIV HCV